HIPAA subcommittee ‘works to level playing field’To tour the 10th floor Harborview Tower offices of Hospital Patient Accounting, who’d guess the crew quietly going about its work there was really in heated competition for the gold?“Every day’s a contest,” said director Paul Weaver, displaying immense pride in his team. From where he stands they defend daily MUSC’s title as a premier academic medical center as surely as the U.S. Olympic Team competes for coveted medals. Weaver, with CCIT’s Dave Northrup, heads MUSC’s subcommittee to establish standards in the coding of patient information and electronic exchange of specific health care transactions. Their work is essential in the effort both to collect from payers and to reconcile patient billing discrepancies promptly, and that will help MUSC stay financially sound, they said. “The subcommittee works to level the playing field,” Weaver said. He and Northrup work under the direction of the university steering committee charged with making MUSC compliant with federal regulations spelled out in the Health Information Portability and Accountability Act (HIPAA). Their Electronic Transaction and Code Set Standards subcommittee works among the MUSC entities providing patient care, the vendors who route claims to third-party payers, and the insurance companies who ultimately issue the checks that keep MUSC in business. Northrup traces the committee’s charge to streamline the provider reimbursement process to federal administrative simplification initiatives in the early 1990s. When it became obvious that voluntary compliance was unworkable, Congress enacted and President Clinton signed into law the Health Information Portability and Accountability Act of 1996. The act not only sets standards for electronic transactions, but mandates safeguards for privacy and security of patient health information and proposes national standard identifiers to eliminate billing and data exchange problems. Although HIPAA compliance is mandatory and may be temporarily painful for some, Weaver expects MUSC will realize significant money-saving benefits once its goals are met. “Through the teamwork of our financial service departments including admissions, medical records, managed care, decision support and revenue service and audit, we strive to improve the cash performance of our institution and benchmark ourselves against university medical centers nationwide.” Weaver said. The MUSC Medical Center logs 600,000 patient visits each year, each of which triggers a series of administrative transactions to ensure payment. A claim is submitted from the provider to the payer. The provider queries the payer about the patient’s eligibility (for example, is the patient Medicare-eligible right now?). And there’s the pre-certification/pre-authorization request. When the remittance arrives—perhaps from Blue Cross/Blue Shield—it may be a check for more than $350,000 accompanied with a record showing detail account information. That information is the amount paid for each patient claim—there could be hundreds—that then has to be entered and accounted for at MUSC’s end. Claims that aren’t paid have to be checked and additional information passed on to the payer. Some transactions are electronic, some are on paper, and they all involve processes that vary among provider entities within the medical center and among the health insurance companies big and small scattered worldwide. According to the HHS Health Care Financing Administration, about 26 cents of every health care dollar is spent on administrative overhead. Standardization of electronic transactions and code sets will drive down costs by accelerating cash flow from payers to providers, by reducing the number of people required for the process and by eliminating and more quickly reconciling errors. “It will create a fair playing field for everyone,” Weaver said. “Everybody will be doing it the same way.” And it will give him the tools he needs to work more effectively with payers, he said. Currently, the committee is busy identifying and meeting with each MUSC entity that bills outside the MUSC campus for payment, Northrup said. Process standardization requires work with the electronic equipment and software used, training in the process standards, and coordinating the activities with vendors that route MUSC claims to payers. For a goal to shoot for, Weaver and Northrup have only to look over
their shoulders at the full automation example set by the pharmacy industry.
“They collect their co-pay up front, submit the claim and are paid in a
fraction of the days it takes us,” Weaver said.
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